Jul 182016

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

Want to read the review for yourself? The abstract is publicly available.

Aug 302014
Image of needle and syringe - click through to see source

Needles and syringes no longer look like this. Isn’t that wonderful?

Testosterone therapy for transgender men, and others who desire testosterone supplementation, typically involves intramuscular injections of testosterone. Intramuscular injections deliver the medication deep within a large muscle — typically a thigh muscle. From there the hormone can slowly work its way into the bloodstream to do its magic. Few other options exist, and those that do are either expensive or less effective (e.g., creams). Testosterone should not be taken as a pill because it’s very bad for the liver in that form. One possible alternative that has been discussed recently is subcutaneous testosterone injections.

Subcutaneous injections go just under the skin. Most people don’t get subcutaenous injections. The most common subcutaneous injection may be insulin injections for people with diabetes. Subcutaneous injections are also how fluids are given to cats in veterinary care.

Subcutaneous testosterone has been in sporadic recent use for trans men without any research showing how well it works. But that’s changed now with the publication of the article I’m going to summarize. 🙂 So let’s hop into it!

This was a study involving 36 male-identified trans youth from ages 13-24 (minors had parental consent). None had been exposed to hormones before. Hormone levels and other lab values were measured at the beginning and after six months.

For those interested in the specific technicalities of how the hormone was given, keep reading this paragraph. For those not, skip down to the next one! They were given testosterone cypionate suspended in sesame oil that was made at a local compounding pharmacy. The young men were given the injections by the clinical staff at first, but slowly taught to self-inject. Dosing was biweekly and started at 25mg per week, slowly increasing after that for some with a final dose ranging from 25-75mg.

So what did they find? How did it go? Positively!

About 92% of the young men in this study had testosterone levels in the “male” range at the 6 month check up. Similar goes for estrogen levels — by that 6 month check up their estradiol levels were down in the “male” range too. 85% of the young men who had been menstruating had stopped by that 6 month check up. Most periods stopped roughly around the 3 month mark. Other factors, like hemoglobin (red blood cell concentration) and cholesterol shifted but were not of clinical significance.

Two of the young men had allergic reactions to the sesame oil and were switched to cottonseed oil. This is a pretty well known reaction that happens in intramuscular injections too. Some also noticed small bumps around where they injected for a few days after injection. Those were the only reported side effects. Nobody reported unhappiness with their testosterone treatment method or asked to be switched to a different method.

All in all, a well put together study. Subcutaneous injection of testosterone so far appears to be a possible alternative to intramuscular injection. But it’s worth noting that commercial testosterone is intended for intramuscular injection and that type is not what was tested here. It may not be safe or effective to inject an intramuscular formulation as a subcutaneous one — ask your physician before changing how you use your medications!

As always: this is just one study. More need to be done to confirm these results. Regardless, I think these are good first results and look forward to seeing more.

Study was published in LGBT Health. Abstract is publicly available.

Disclaimer: I have personally met Dr. Olson (lead author of this study), worked with her in a small capacity, and have attended her talks at conferences. My interactions and impressions of her may have biased my interpretation on this study. However, I do my best to keep those preconceptions from affecting my judgment.

Feb 262014

Got ethics ?Summary: Evaluation and review of proposed ethical principles for genital surgery for minor transgender women.

The WPATH Standards of Care are the international guidelines for health care for transgender people. Among other items, the standards detail requirements, risks and expected results for various therapies. The most recent version of the SOC, version 7, requires that transgender people be at least the age of majority to have genital surgery. In the United States, this is age 18. This presents a problem for trans adolescents who may want genital surgery earlier.

The paper I’m reviewing today took a look as some of the factors involved in deciding the ethics of genital surgery for young trans people. With more trans people transitioning at an earlier age than ever before, demand for surgery at a younger age seems to be going up. There have been cases, some prominent and some not, where a trans person (usually a trans girl) received genital surgery before they reached the age of majority.

As the author, Dr. Christine Milrod (PhD) points out, there are no ethical standards for determining if surgery is the right choice for a minor trans person. In this article Dr. Milrod discusses factors related to genital surgery, relevant background for an ethical standard, and tentatively proposes a set of standards. Because the article itself is behind a paywall, I’m going to roughly summarize the points she brings up as well as summarize her proposed standards.

Dr. Milrod seems to be focusing on young trans girls because they seem to be the ones accessing surgery as minors. Much of what she says is applicable to trans boys as well.

Issues and factors relating to genital surgery in adolescent trans people

  • Lack of genital surgery exposes them to a potential accidental exposure of their trans status, which may not be to the young person’s benefit. Stigma, shame, and feelings of inadequacy may result.
  • Trans youth are at very high risk for discrimination and harassment, which impacts both their physical and mental health. The ability to pass (including surgery) may reduce or eliminate the risk of discrimination/harassment.
  • Genital status may impact a young trans person’s ability to start a romantic or sexual life.

So what’s the current status when it comes to Standards?

WPATH states that an individual must be the age of majority for genital surgery. The Endocrine Society generally agrees. However, Dr Milrod points out that this is not necessarily always followed. She points to some Dutch clinics where the policy is essentially “no genital surgery until age 18” even though the age of majority in the Netherlands is 16.

Dr. Milrod points out that the current standards try to find a balancing point between minimizing the waiting time for a trans youth with limiting chances of post-surgical regret. However in the same section she points out that studies of Dutch youth 1-4 years after surgery finds no regret whatsoever.

Some quick background information on age of majority and informed consent from my own research, courses, and so on…

The age of majority is the age at which a person can legally give informed consent to a medical treatment. Informed consent means that the individual has been told all the possible risks and benefits of an activity/treatment/research, has understood them, and is agreeing to the activity/treatment/research. It’s an extremely important concept in medicine, psychology and human-related research, one that has emerged out of human rights abuses. An important part of informed consent is that the person being asked for consent has to be capable of giving it, and giving it freely. A person who is mentally altered, such as a person who’s consumed a large amount of alcohol, is not considered able to consent because their judgment is altered. A person who is mentally disabled or who has something like dementia is also considered not to be able to give consent.

And then there are minors. Because their ability to comprehend and judge accurately all the risks/benefits may not be fully developed yet, a minor is not considered able to give consent. Before the age of majority, it is the legal guardians of the young person who give consent on behalf of the young person. The young person instead gives assent – they can agree or not agree to something, but it doesn’t have the full meaning of consent.

So what does informed consent have to do with genital surgery? A lot. Can a person under the age of majority agree to something as irreversible as genital surgery? Does it do more harm than good, or is there more harm in making them wait? Surgeons, physicians, therapists, parents, and young people themselves are currently wrestling with these issues.

Dr. Milrod points out some things on informed consent in addition to my summary. The regulations and laws on informed consent vary very heavily from country to country and from region to region, and vary depending on the procedure involved. For example, in Australia a minor cannot receive genital surgery even with parental consent without a court order. However in some areas of the United States, a minor could petition to become an emancipated minor and thus be legally responsible for themself and consent to treatment. In other words… whether or not a young person can consent is heavily debated. Can a person at age 16 consent? 14?

Proposed “Principles for Decisions Concerning Genital Surgery of the Adolescent”

First, Dr. Milrod notes that recommendations regarding the surgical treatment of intersex infants and children were part of the framework for her principles

  • The Principle of Psychological Support and Education: The young person and their parents/guardians should be given both full education regarding the surgery and full emotional and psychosocial support. They should be given all the information: all the risks, benefits, potential side effects, permanency, and alternatives. They should be given room to sort through emotions and pressures. This heavily implies and almost requires the presence of a therapist for both the young person and their family members.
  • The Principle of Medical Management: Only a surgeon experienced in transgender genital surgeries should perform such a surgery on an adolescent, and that surgeon is responsible for providing complete information on the procedure and post-operative management. If the surgeon approached declines to perform the surgery, they should offer a reasonable explanation and a referral.
  • The Principle of Risk: Naturally, all risks should be minimized as much as possible. The physicians and surgeons involved are responsible for evaluating the physical risks of surgery for the young person. The psychosocial risk (of either performing surgery or delaying) falls to the therapist and/or other mental health professionals involved. The familial and social standards surrounding the young person also need to be taken into account.
  • The Principle of Human and Legal Rights: The young person must have given “full, free, and informed consent” to the surgery. All professionals involved must be in agreement that the young person is capable of giving such consent and has given it. The young person should be treated as any other patient with regard to privacy laws.

These aren’t exactly earth shattering. Rather, I think they’re very conservative measures. Conservative is not necessarily a bad thing. In my clinical experiences so far, I’ve come to view any hard and fast rule about transition with suspicion. One person may truly need a year of “real life experience” before hormones, for another that may be dangerous, and for yet another that may simply be an unnecessary postponement of hormone therapy.

This seems to me to be especially true for minor trans people, who have their families and schools and their vulnerable legal status to contend with. So I think Dr. Milrod did right in setting such conservative principles/guidelines. Each person must be treated individually – the possibilities are simply too broad and too serious to be treated otherwise.

If you’re interested in finding out more about issues facing transgender and gender nonconforming youth and their families, please check out Gender Spectrum. A more loving, kind, knowledgeable organization on the topic I have yet to find. Their professionals and family conference is wonderfully informative and supportive. I’ll be there this year if my medical school plans allow.


Sep 242013

This post is a legacy page, and was part of an on-going series, Trans 101 for Trans People. It covers questions about medical transition, hormones, surgeries, or seeking health care for transgender people.

For the material that once lived on this page, please see this page.

Please update your links to the full Trans 101.

Jul 172013

Gender Spectrum

Gender Spectrum has a yearly Family Conference and Professionals Workshop in Berkeley, California. This year was the 7th conference, and my 3rd time attending (2nd year as a volunteer). Gender Spectrum is an organization supporting, educating and advocating for transgender and gender non-conforming youth and their families.

I’ll start by talking about the Professional’s Workshop, which was Friday. It was roughly split into four tracks: medical, mental health, legal, and educational. There was a lot of overlap. One panel I particularly enjoyed was the “Working With Caregivers” panel. It was a series of cases and discussion of those cases between a family practice physician and a social worker. The varying concerns in each case , the individuality, and the back-and-forth between professional fields really helped bring the case reports to life. For someone like me with limited clinical experience it was a real treat. Another panel I really appreciated was on research relevant for trans youth. The summary? As usual, not much… but I do have a few more citations to track down and read.

I also want to give a shout out to Jeanne Nollman (and, by extension, the AIS-DSD Support Group) for coming and giving an Intersex 101 talk and sharing her story. This was the first year Gender Spectrum addressed intersex/DSD issues and it’s sorely needed. As much as trans issues are hidden from the public eye, intersex issues are even more hidden… often by medical professionals and families themselves. Thank you Jeanne for stepping into the light and talking with us. Let’s create some change there too!

The last panel I attended in the professionals workshop was on fertility. It was repeated for the family conference. Many many families are concerned that, by allowing their children to start hormone therapy or have surgery, that they will forever lose their ability to have biological children. I see two aspects to this: the (often complex) biology of fertility and fertility preservation, and the emotional aspects of family and family building. Before the conference began, I coordinated with several of the presenters to help make a flow chart to simplify explaining the fertility biology.

The family question is, in a way, a lot harder. What is family? Who is family? For many, biological grandparentage is important. For others, they simply don’t want to sterilize their child. I was more emotionally involved in the conversation than I expected to be. I believe very strongly that family is chosen, not just biological. I have more than two parents. I accept them all whole heartedly, and I don’t make a distinction based on genes. But I admit that the dominant culture I see in California doesn’t accept that… and we lack language that truly supports that. Worse, much of my family is not legally recognized. So it’s a bit of a tangle of an issue. As far as I know this was the first year fertility was addressed in a panel. It went very well, and I hope to see it repeated and expanded next year.

As for the family conference? I heard rumor that some 150-200 youths were there. It was huge this year! My volunteering this year was primarily focused on the medical consult sessions. Every year the conference offers one-on-one sessions with various professionals. This year it included medical, mental health, spiritual, and legal professionals. It was pretty busy. I didn’t get to as many panels as I might have liked, but that’s nothing strange. As always at a conference, one wants to be in five different places all at the same time. So unlike previous years, I didn’t come home with a folder full of notes and citations to look up. Instead, I sat and talked with people.

It was a surprisingly intense and emotional conference for me. I really came out of the world of statistics and risk factors and into the world of emotions and realities. It was… well, I’m still looking for the right words. I appreciate all the people who sat and talked with me. I hope you’re all well. Know that someone in the world is thinking of you and hoping everything’s going to come out OK in the end. Another shout-out, this time to Micah of Neutrois Nonsense. Good to see you again!

One theme stands out for me this year particularly strongly: self-determination. The goal of Gender Spectrum, and of the parents there raising trans and gender non-conforming youth, is to let their children be themselves. Whatever that is at that particular moment. Let them explore and play and decide what’s right for themselves in the end. It’s like Maslow’s Hierarchy of Needs: provide the safety, security and love and let the child self-actualize and be happy.

At the closing plenary for the conference, we were asked “What’s the one thing you’ll do with this experience when you leave here?” For me? I need to revise my Gender and Sexual Minorities 101 lecture. I may accept the gender binary for myself (I identify as a woman), but that doesn’t mean I should assume others do. I think I emphasized the binary too much in my previous lectures. So when I record those lectures, it’ll be a revised version that’s more open to gender fluidity, and that provides more information on trans and gender non-conforming youth.

…also, I so need to bring business cards next year! Augh! Oh well. Hope everyone I gave contact info to is able to find me. 🙂

In summary? Great experience, as it is every year. If you are a family with a trans/gender non-conforming youth, or work with those youths, or do trans care of any flavor, or are just curious…. please try to come for next year! I hope to see you all there again soon.